Coaches/Board Members-Northlake Surge Soccer Club Spring 2026 Registration

Northlake Surge Soccer Club

Spring 2026
New York State West Youth Soccer Association
Please fill out the required medical/insurance form here:

Medical/Insurance

This is required for each player.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Date of Birth*

MonthDayYear
Date
First year players, send birth certificate to: surgesoccerclubny@gmail.com
Gender: *

MaleFemale
Parents: Please note, if you are a new player, you will need to select an orange and a black jersey, shorts, and socks. This is the required kit for Surge Soccer.

Returning players: Select any replacement kit items you need or select, Not Needed, if you do not need replacements.
Uniform Shirt Size-ORANGE Jersey (Returning Players-Replacement Cost $35 each.)*
Uniform Shirt Size-BLACK Jersey (Returning Players-Replacement Cost $35 each.)*
Socks (Returning Players-Replacement Cost: $10)*
Uniform Shorts Size (Returning Players-Replacement Cost: $15)*
Parent Name*
Parent Phone number *
Alt Phone
List any medical problem or prohibition player may have
Person to notify in emergency*
Phone*
Doctor to notify in emergency*
Phone*
Important I, or the parent/guardian of the registrant, a minor (if under 18), agree that I and the registrant will abide by the rules of the NLSSC, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the NLSSC accepting the registrant for its soccer program and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify the NLSSC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of registrant's participation in the Programs, and/or being transported to or from the same, which transportation I hereby authorize.
Player Signature (if over 18)

Clear
Date

MonthDayYear
Date
A registration form is required for each player.

New Surge players-$225 (This includes your reusable uniform.)

Returning Players:

If no uniform items are needed, please pay $125.

If uniform items are needed, please add appropriate cost to the $125 player fee.

We must receive (birth certificate-new players ONLY)registration, Venmo/Payment, and medical form for all players by February 10th. No late registrations will be allowed.
Registration Options:
prevnext( X )
Single Player Registration-New Player Please pay and register each player separately.
$225.00



Returning Player RegistrationPlease pay and register each player separately.
$125.00



Returning Players Only-Orange or Black Uniform Shirt
$35.00



Returning Players Only-Shorts
$15.00



Returning Players Only-Socks
$10.00



Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty: